Neurologic Emergencies Flashcards
(84 cards)
1
Q
Status epilepticus definition
A
5+ mins of clinical or electrographic seizure activity OR 2+ seizures without recovery in between
2
Q
Refractory status epilepticus
A
Failure of benzo + 1 AED
In 30% patients
20% die
3
Q
SE Rapid initial management
A
- Airway - oral, lateral decubitus
- Breathing - bag mask, O2, sat probe, RT
- Circulation - cardiac monitor, IV access
- Check glucose
4
Q
SE Initial management
A
1 abortive and 1 maintenance drug
Abortive - early
- Lorazepam 0.1 mg/kg
- Diazepam 0.2 mg/kg
- Midazolam 10 mg
Maintenance
- Phenytoin - 20 mg/kg
- Fosphenytoin 20 mg/kg
- Valproic acid 40 mg/kg
- Levetiracetam 60 mg/kg
5
Q
Refractory SE Management
A
- ICU
- Midazolam infusion
- Propofol infusion
- Pentobarbital infusion
Aim for burst suppression for 24 hr before taper
Monitor for NCSE with continuous EEG
6
Q
SE Investigations
A
Labs
Glucose, ABG, lactate (up), CBC (inc WBC), lytes (hypoK), extended lytes (all hypo), Cr up, NH4 up, tox screen Les, AED level (don’t tx level), prolactin up, beta HCG
Imaging
- CT head (tumor, pus, blood)
- MRI brain (cortical lesion)
- EEG
7
Q
SE Tx Cause
A
Metabolic
- Hypoglycemia - thiamine, D50
- Restart missed AEDs
- Tx withdrawal
- Tx toxicity
- Correct lytes -Na, Ca, Mg
Structural
- Meningitis
- Encephalitis HSV1>2
- Stroke
- CVT
- Ischemic encephalopathy
- HTN - PRES
- Autoimmune
8
Q
Epilepsy definition
A
2+ unprovoked seizures >24 hr apart OR
1 unprovoked seizure with >60% recurrence risk OR
Epilepsy syndrome
9
Q
Focal seizure
A
- Aware or impaired awareness
- Motor or non motor onset
- Focal to bilat tonic clonic
EEG - focal IEDs, slowing
Rx - epilepsy surgery
10
Q
Generalized seizure
A
Motor - tonic clonic, myoclonic, atonic, tonic, clonic
Non motor - absence
EEG - generalized spike and wave
Rx
- AEDs
- Vagal nerve stimulator
- Ketogenic diet
11
Q
Unknown seizures
A
Motor or non motor
Tx
Broad spectrum AEDs
12
Q
Seizure features vs other causes
A
Prodrome/Risks - Sleep deprived, from sleep, photic stimulation, hyperventilation, alcohol use During spell - Positive sx - Vocalization - Deju vu - Epigastric rising - Head turning - Incontinence - Flushing - Tongue biting Postdromal - Tongue biting - Confusion, somnolence - focal neuro deficit
13
Q
Syncope features vs. other causes
A
Prodrome/risk - Light head, sweat, sit/stand, defecation/micturition, palps During spell - Brief convulsions - Pallor, diaphoresis Postdromal - Alert
14
Q
TIA features vs. other causes
A
Prodrome/risk - CV risk factors During spell - Negative symptoms - Sudden onset - Max deficit at onset - <10 mins Postdromal - Alert
15
Q
Migraine aura features vs. other causes
A
Prodrome/risk - FHx - Motion sickness, cyclical vomiting, adverse childhood experience During spell - Gradual migration of sx over 5-60 mins - Scintillating scotomas - Paresthesias - Positive and negative sx Postdromal - Sev, unlit throbbing HA - Photo/phono/osmophobia - N/V
16
Q
Risk of recurrence
A
21-45% after first - greatest in first 2 years
60%+ if abnormal EEG or MRI
EEG
- Routine low yield ~30%
- 50% within 24 hrs event
- 50% sleep deprivation
- 70% serial EEGs
17
Q
AED Options - Broad
A
Valproate Lamotrigine Levetiracetam Clonazapam Clobazam Topiramate
18
Q
AED Options - Focal
A
Avoid in idiopathic generalized: Carbamazepine Oxcarbazepine Eslicarbazepine Phenytoin Gabapentin
Okay:
Phenobarbital
Pregabalin
Lacosamide
19
Q
AED Options - Absence
A
Valproate
Ethosuximide
20
Q
AED Options - Myoclonic
A
Valproate
Levetiracetam
21
Q
AED Tolerability and other SFx
A
SCARED-P Sedation Cog impairment Ataxia/dizzy Rash Emesis/GI Diplopia/visual change Pregnant - NO VALPROATE
Other
- OP
- HypoNa - carb, oxcarb, eslicarb
- Psych - levetiracetam
- SJS - carb, oxcarb, pheny, lamo
- PR long - lacosamide
- Weight gain - VA
- Weight loss - topi
- CI - topi, clobazam
- Sedating - clob, phenobarbitals
22
Q
AED Adherence and cost
A
BID>TID
Newer most expensive than older
23
Q
AED in pregnancy
A
Levetiracetam
Lamotrigine
24
Q
AED Interactions
A
- Renal - levetiracetam
- Valproate CYP inhibitor
25
AED Mood stabilizers
Valproate
Lamotrigine
Carbamazepine
26
Epilepsy Safety/Driving
- Avoid climbing, swimming, driving
- MedicAlert
Driving
- 1st seizure unprovoked = 3 months
- Epilepsy - 6 mos seizure free on meds
- Medication change - 3 mos
27
Epilepsy non pharm management
- Stop alcohol and drugs
- Sleep hygiene
- Trigger avoidance
- Screen anxiety, dep, SI
28
GBS Defn
Acute monophasic inflammatory demyelinating polyradiculoneuropathy
Causes sensory loss, ascending paralysis, areflexia
29
GBS Risk Factors
Infection - C jejeni, flu, HIV, Zika
| Influenza >>> flu shot
30
GBS Treatment
```
Nonambulatory patients within 4 weeks of symptoms
1. IVIG - 2g/kg over 2-5 d
OR
2. PLEX
- No steroids
- Don't use both
```
31
GBS Acute management
1. ABCs - tele, BP, FVC q4h
2. Intubate if:
FVC<20
MIP 0 to -30
MEP <40
32
Predictors of resp failure in GBS
```
30% patients have it
Onset to admission <7 d
FVC <60% predicted
Facial weakness
Inability to cough, lift head, lift arms, stand
```
33
Dysautonomia in GBS
```
70% of patients have it
Sinus tachy
Paroxysmal HTN
Ortho HOTN
Brady, AV block
Urinary retention
Ileus
```
34
Investigations in GBS
- FVC
- PVR
- MRI whole spine with Gad (R/O acute myelopathy)
- CBC, lytes, BUN, Cr, INR/PTT
- LP - albumincytologic dissociation (protein >0.45, WBC <5, if WBC high check HIV)
- EMG/NCS = absent F waves, conduction block (best 2 wks post)
- Anti Gq1b Ab
35
History GBS
Monophasic
85% walking by 1 year
5% go on to have chronic inflammatory demyelinating polyradiculoneuropathy
Tx: IVIG or steroids
36
CIDP Defn
- Most common chronic AI neuropathy
- Progressive symmetrical proximal and distal weakness, large fibre sensory loss, areflexia, fatigue over 2 mos
- Usually spares CN, resp, autonomic
37
CIDP Dx
1. EMG/NCS - acquired demyelination
2. CBC, lytes, liver renal, thyroid B12, A1c, SPEP/UPEP, immunofixation, FLC, methylmalonic acid
3. Maybe LP
4. Maybe MRI spine with gab
5. Maybe nerve U/S
38
CIDP Tx
1. IVIG q3 week
| 2. Pred 1 mg/kg
39
When to suspect treatable neuropathy
Typical pattern
- Distal symmetric polyneuropathy
1. Paresthesia migrate feet to legs
2. Lose ankle reflexes
3. Dec sweating in feet
4. Atrophy extensor digitorium brevis
5. Toe flexor/extensor weakness
6. Paresthesias at knees --> fingertips
Red flags
1. Asymmetrical
2. Acute onset
3. Early motor involvement
4. Sig autonomic involvement
40
Myasthenia Gravis Features
Autoimmune destruction of the POST synaptic NMJ
Bimodal - young F 20s, old M 60s
Fatiguable weakness:
1. Ocular - ptosis, binocular diplopia, pupil sparing
2. Bulbar - dysarthria, dysphagia, chewing fatigue, head drop
3. Resp - orthopnea
4. Extremities - prox>distal weakness
41
MG Investigations
1. PFT - FVC
2. Serum AChR Ab
3. EMG/NCS
- RNS (rpt nerve stimulation)
- SFEMG
4. CT chest - R/O thymoma
5. CBC, lytes, Cr, TSH, CK
42
Acute Management Myasthenic Crisis
1. ABC
2. Intubate if:
FVC <20
MIP 0 to -30
MEP <40
43
Immunosuppression myasthenia crisis
1. PLEX or
2. IVIG 2 g/kg over 2-5 d
Hold pyridostigmine while intubated
Caution high dose pred = worsen resp
44
Maintenance Tx MG
```
Symptoms
1. Pyridostigmine 60 TID - GI, cholinergic crisis, bronchorrhea
Disease Modifying
1. Prednisone
2. Azathioprine
3. MMF
4. PLEX
5. IVIg
6. Eculizumab
```
45
Thymoma in MG
If thymoma = refer to surgery
| If no thymoma - elective if <60 yo, AChRAb pos, disease <5 year
46
Drugs to avoid in MG
1. Anesthestic - NM
2. ABx - FQ, AG, macrolide
3. CV - BB, procainamide, quinine
4. Anti PD1 MAbs - nivolumab, pembrolizumab
5. Botulinum
6. Chloroquine/HCQ
7. Mg, Li
8. Steroids - in crisis
47
Headache DDx Primary
```
Primary
1. Migraine
2. Tension
3. Trigeminal autonomic cephalalgia
Other: cluster, paroxysmal hemicarnia, SUNCT/SUNA
Secondary
DANGEROUS
```
48
HA Ddx Secondary
```
Vascular
- Ischemic stroke/thrombosis
- Hemorrhage
- Dissection
- GCA
- PRES
- Pituitary apoplexy
- AVM
Space occupying
- Tumor
- Hydrocephalus
- Idiopathic intracranial HTN
Infection
- Meningitis, encephalitis, abscess
- Sinusitis, otitis
Ophtho
- Acute glaucoma
- Iritis
- Optic neuritis
```
49
Red flags in HA
```
SNOOP4
Systemic - fever, wt loss, IS
Neuro - s/sx
Onset - thunderclap
Older >50
Pattern change, positional, pulsatile tinnitus, precipitated by cough/valsalva
```
50
Secondary HA Investigations
1. CT/CTA/CTV H&N
2. MRI Brain
Other
1. CBC, lytes, Cr
2. ESR/CRP - GCA
3. DVT - CVT
4. Blood cultures
5. LP
51
Idiopathic Intracranial HTN
Headache plus:
Transient visual obscurations
Pulsatile tinnitus
Weight gain
52
Spontaneous intracranial HOTN
HA plus worse standing
53
Meningitis
Headache
Fever
Photophobia
Neck stiffness
54
HSV Encephalitis
HA
Fever
Encephalopathy
55
GCA
```
HA
Fever
Weight loss
Scalp tender, jaw claudication, transient monocular vision loss
proximal myalgias
Anemia
```
56
Reversible cerebral vasoconstriction syndrome
HA
Recurrent thunderclap
Pregnant
Cannabis/decongestant use
57
PRES
HA
HTN
Cyclosporine/tac
58
Dissection
HA
Neck pain
Horner syndrome
59
Pituitary apoplexy
```
HA
Vision loss
Diplopia
HOTN
Pregnant
```
60
Dx Migraine w/o Aura
5+ HA attacks lasting 4-72 hr with no better explanation
2 of:
1. Unilateral
2. Pulsatile
3. Mod-sev
4. Aggravated by/avoid routine physical activity
PLUS 1 of:
1. N/V
2. Photo/phonophobia
61
Tx of status migrainosus
Oral
1. NSAID - ASA, diclofenac, Ibuprofen, Naproxen
2. Acetaminophen
3. Triptans
Parenteral
1. IVF
2. MgSO4
3. Antiemetic - maxeran, domperidone
4. Ketorolac
5. Dexamethasone
Peripheral nerve block
Neurostimulation
NO OPIOIDS, BARBITURATES
62
Multiple Sclerosis Epi
```
F>M
Northern Europeans
Relapsing remitting type 90%
Primary progressive
Secondary progressive
```
63
Clinically isolated syndrome
First demyelinating attack
Monophasic clinical episode of acute or subacute onset
Patient reported symptoms
Findings typical of MS
Reflects a focal or multifocal inflammatory demyelinating event in CNS +/- recovery
No fever or infection
If MRI lesions 70% develop MS
If non 20% develop MS
64
MS Optic neuritis
Painful eye movements
Monocular vision and colour loss or scotoma
RAPD
1/3 mild disc swelling
65
MS Brainstem/cerebellar syndrome
```
Bilateral INO
Diplopia
Dysarthria
Ataxia
Gaze evoked nystagmus
Vertigo
Facial numbness
CN6 palsy
```
66
Incomplete transverse myelitis
```
Sensory loss
Asymmetric limb weakness
Urge incontinence
ED
Lhermitte - neck flexion = spinal electric shock sensation
```
67
Uhthoff phenomenon
Heat exacerbation
68
Ddx MS
1. Demyelinating - ADEM, NMO, MOG
2. Inflammatory - Sarcoid, SLE, Sjogrens, GPA, Behcets
3. Infx: post infxn demyelination, HIV, PML, HTLV, syphilis, Lyme, Bartonella, TB
4. Metabolic - B12/Cu def
5. Lymphoma
6. somatization
7. Vascular - vasculitis, malformation, migraine
69
Macdonald Criteria for RRMS
1. MS most likely AND
2. 1 CIS AND
3. Dissemination in space and time
```
DIS
- 2+ clinical attacks OR
- 2+ lesions in 2+ of regions
DIT
- 2+ clinical attacks OR
- 1 MRI: gad enhancing and non enhancing lesions OR
- 2 MRIs - new T2/gad lesion on F/U scan OR
- CSF specific oligoclonal bands
```
70
MS Investigations
1. MRI brain and CT spine with gad
2. LP for oligoclonal bands IgG index
Other
- Basic lab work
- B12, TSH, SPEP
- ANA, ESR, CRP, ENA, ACE, ANCA
- VDRL, LYME, HIV, HTLV
- Visual evoked potentials
- NMO/MOG Ab
71
Treatment MS attack
If functional disabled = high dose CS speeds recovery
- Optic neuritis
- Motor weakness
Doesn't change degree of recovery or reduce risk of future attack
Methylpred 1000 mg IV daily 3-7 d and taper
PLEX if poor steroid response
72
Disease modifying therapy RRMS
- Decrease relapse rate
- Decrease MRI brain lesions
- Lower risk conversion
```
Injections
- Beta interferon
- Glatiramer acetate
Oral
- Dimethyl fumarate
- Teriflunomide
- Fingolimod
- Siponimod
- Cladribine
Infusion
- Natalizumab, alemtuzumba, ocrelizumab
HSCT
Lifestyle
- Physical activity
- Stop smoking
- Vit D 4000 IU daily
```
73
Neuro manifestations COVID
```
Anosmia
Ageusia
Acute ischemic stroke
Encephalopathy/encephalomyelitis
HA
Mylagia, rhabdo
ICH
GBS
Bell's palsy
```
74
Encephalopathy Management
1. ABC
2. Thiamine, dextrose, Naloxone
3. Hyperthermia - cooling blankets, antipyretics
4. Consider empiric ABx/antivirals
Inv
- Tox screen
- CT/MRI head
- EEG
- LP
75
Herpes Encephalitis
```
HSV1 reactivation
<1 wk AMS, aphasia, ataxia, memory, focal seizure
Inv
- MRI
- LP - inc RBC, lymph's, glucose normal
- EEG - high amp slow waves
- HSV CSF PCR
```
76
Otologic Vertigo
```
Sx
- Hearing loss, Tinnitus, Aural fullness
- Severe vertigo
- Head trauma
- With head postures, cough
Exam
- HINTS benign
- Unidirectional nystagmus
- Dix Hallpike positive
Ancillary
- Audiology
- Vestibular testing
- CT temporal bone
```
77
Neurologic Vertigo
```
Sx
- Diplopia
- Dysphagia, dysarthria
- Hemiparesis, hemisensory loss
- Migraine, MS, stroke
Exam
- HINTS concerning
- Direction changing nystagmus
- Skew deviation
- Horner
- Ataxia
- Focal weakness
- Gait instability
Ancillary
- MRI brain
```
78
Medical Vertigo
```
Sx
- Syncope, SOB, palps
- Only when standing
Exam
- Murmur
- Ortho HOTN
Ancillary
- Holter, echo, lytes, med review
```
79
Psychogenic vertigo
```
Sx
- Constant for mos
- Panic attacks
Exam
- Positive signs: Hoover sign, distractibility, suggestibility, entrainment, waxing/waning
```
80
HINTS Exam
Peripheral vs central vertigo
1. Head impulse test
- P: abnormal, corrective saccade
- C - normal, no correction
2. Nystagmus
- P: unidirectional, horizontal
- C: horizontal, direction changing, vertical, tosional
3. Test of Skew
- P: no skew deviation
- C: skew deviation
81
Lateral medullary syndrome (Wallenberg)
```
Infarct of vertebral or PICA
- N/V, vertigo
- Ipsilateral Horner
- Ipsilateral face pain/temp loss
- Contralateral body pain/temp loss
- Ipsilateral cerebellar ataxia
- Ipsilateral dysphagia/dysarthria
- Hiccups
NO LIMB WEAKNESS
```
82
Horner's syndrome
Miosis - constrict
Ptosis - droopy lid
Anhidrosis - no sweat
Damage to sympathetic nerves
83
Bell's Palsy
Unilateral drooping
Ptosis
Cannot close eye
84
Pregnancy considerations
```
Epilepsy
- Avoid AEDs - valproate
- Drug level monitor
MS
- Improved relapse rate, inc risk PP 3-4 mos
- Methylpred tx
- Glatiramer and interferon best for immediate pregnancy
HA
- Tylenol, sumatriptan, nerve block, neurostimulation
Stroke
- Risk permpartum to 6 weeks post
- avoid gad
- offer TPA/EVT
```
